At the time of departure of the THOMASRENNIE from Centre Island (1015), the wind and weather were favourable and traffic was light. The crossing took 12 minutes up to the time of the striking -- an average crossing time. The difficulty the master experienced in stopping the vessel was therefore not likely to have been due to the vessel having made its approach to the dock at a higher-than-average speed. Neither passengers nor crew distracted the master from his conning of the ship. The striking occurred near the start of his shift and analysis of the master's work/sleep cycle showed that he was adequately rested. The tactic he employed to reduce the vessel's forward speed, steering the vessel to strike the dolphin a glancing blow, appears to confirm his alertness and resourcefulness in dealing with the emergency. The horn lanyard was overhead and accessible to the master and there were opportunities to warn the passengers and crew; however, this was not done. Because neither the master nor the EOW looked at the forward engine tachometer when the vessel was approaching the dock, no one observed if the engine responded and acted to cause the vessel to move astern. However, no wash was observed forward as the ferry approached the dock and the deckhand who was below deck forward did not feel the customary forward propeller vibration. Both these factors would appear to confirm that the forward engine, if it responded to the commands reportedly given by the master, did not produce the required rpm and was ineffective. It is unknown why the forward engine was not effective; there may have been a mechanical or control failure or it may have been activated too late to have time to respond. The information available, however, is that the forward engine was activated in time. Further, it is unlikely that the master, with more than 1,000 dockings at this berth, would have forgotten to use the forward engine when he realized that the vessel was not slowing in response to the stern engine commands given. On 11 July, as the vessel was approaching the dock, the EOW noted that the stern engine was turning at 1,000 rpm. It is unknown why the stern main engine did not attain the 1,250 rpm commanded by the master. The difference between 1,000 rpm and 1,250 rpm is analogous to speeds of 6 and 10 knots (going ahead). The hurried air compressor inspection and servicing work done before the occurrence may have accidentally affected one or a number of air lines in the area or have been the source of an undetected air leak. These lines serve both the transmission actuator and the pneumatic fuel valve. A drop in air pressure is known to affect the transmission actuator and to reduce the flow of fuel to the engine through the pneumatic fuel valve. The possibility of transmission actuator slippage and a reduction in fuel flow due to a drop in air pressure could explain why the engine attained only 1,000 rpm and did not deliver enough astern power to stop the vessel. The stern engine transmission can also slip due to low transmission oil pressure but there is no information to confirm that this occurred. There is a history of engine control problems on the ferry. The existence of engine control problems and the causes of these problems were known to both the ferry's and company's shore-based engineers. However, the amount of engine control preventative maintenance carried out by expert contractors had been reduced and there had been little or no preventative maintenance for the last two years. Because an engine control problem of a similar nature arose several days after the occurrence, after considerable effort had been expended to rectify the problems associated with the occurrence, the problem does not appear to have been completely resolved before the ferry resumed its service. It appears that a complete record was not kept of all maintenance carried out on the vessel's engines and control systems. In particular, the work done some two hours before the occurrence was not recorded. Bridge Resource Management and Safety Despite the company's instructions to the contrary, the officer of the watch was permitted to leave the bridge and proceed to the main deck in preparation for the berthing of the ferry. This left the master alone on the bridge to conduct docking manoeuvres and attend to the emergency situation. The master was fully occupied employing his best effort to minimize the vessel's impact on the wharf's structure. In the rapidly developing situation, he could not divert his attention from the task at hand to take on the additional workload of warning the passengers of the impending danger. Consistent with good seamanship practices, established procedures with clearly identified responsibilities and roles distributed between bridge team members based on their area of expertise/experience -- especially with respect to passenger safety -- are essential for ferry operations. In this instance, the officer of the watch left the bridge to attend to a secondary function and the deckhand on duty was standing by with no specific task assigned. This would suggest that optimal use was not made of all available resources, and the important task of warning the passengers in a rapidly developing emergency situation could not be effected.Analysis At the time of departure of the THOMASRENNIE from Centre Island (1015), the wind and weather were favourable and traffic was light. The crossing took 12 minutes up to the time of the striking -- an average crossing time. The difficulty the master experienced in stopping the vessel was therefore not likely to have been due to the vessel having made its approach to the dock at a higher-than-average speed. Neither passengers nor crew distracted the master from his conning of the ship. The striking occurred near the start of his shift and analysis of the master's work/sleep cycle showed that he was adequately rested. The tactic he employed to reduce the vessel's forward speed, steering the vessel to strike the dolphin a glancing blow, appears to confirm his alertness and resourcefulness in dealing with the emergency. The horn lanyard was overhead and accessible to the master and there were opportunities to warn the passengers and crew; however, this was not done. Because neither the master nor the EOW looked at the forward engine tachometer when the vessel was approaching the dock, no one observed if the engine responded and acted to cause the vessel to move astern. However, no wash was observed forward as the ferry approached the dock and the deckhand who was below deck forward did not feel the customary forward propeller vibration. Both these factors would appear to confirm that the forward engine, if it responded to the commands reportedly given by the master, did not produce the required rpm and was ineffective. It is unknown why the forward engine was not effective; there may have been a mechanical or control failure or it may have been activated too late to have time to respond. The information available, however, is that the forward engine was activated in time. Further, it is unlikely that the master, with more than 1,000 dockings at this berth, would have forgotten to use the forward engine when he realized that the vessel was not slowing in response to the stern engine commands given. On 11 July, as the vessel was approaching the dock, the EOW noted that the stern engine was turning at 1,000 rpm. It is unknown why the stern main engine did not attain the 1,250 rpm commanded by the master. The difference between 1,000 rpm and 1,250 rpm is analogous to speeds of 6 and 10 knots (going ahead). The hurried air compressor inspection and servicing work done before the occurrence may have accidentally affected one or a number of air lines in the area or have been the source of an undetected air leak. These lines serve both the transmission actuator and the pneumatic fuel valve. A drop in air pressure is known to affect the transmission actuator and to reduce the flow of fuel to the engine through the pneumatic fuel valve. The possibility of transmission actuator slippage and a reduction in fuel flow due to a drop in air pressure could explain why the engine attained only 1,000 rpm and did not deliver enough astern power to stop the vessel. The stern engine transmission can also slip due to low transmission oil pressure but there is no information to confirm that this occurred. There is a history of engine control problems on the ferry. The existence of engine control problems and the causes of these problems were known to both the ferry's and company's shore-based engineers. However, the amount of engine control preventative maintenance carried out by expert contractors had been reduced and there had been little or no preventative maintenance for the last two years. Because an engine control problem of a similar nature arose several days after the occurrence, after considerable effort had been expended to rectify the problems associated with the occurrence, the problem does not appear to have been completely resolved before the ferry resumed its service. It appears that a complete record was not kept of all maintenance carried out on the vessel's engines and control systems. In particular, the work done some two hours before the occurrence was not recorded. Bridge Resource Management and Safety Despite the company's instructions to the contrary, the officer of the watch was permitted to leave the bridge and proceed to the main deck in preparation for the berthing of the ferry. This left the master alone on the bridge to conduct docking manoeuvres and attend to the emergency situation. The master was fully occupied employing his best effort to minimize the vessel's impact on the wharf's structure. In the rapidly developing situation, he could not divert his attention from the task at hand to take on the additional workload of warning the passengers of the impending danger. Consistent with good seamanship practices, established procedures with clearly identified responsibilities and roles distributed between bridge team members based on their area of expertise/experience -- especially with respect to passenger safety -- are essential for ferry operations. In this instance, the officer of the watch left the bridge to attend to a secondary function and the deckhand on duty was standing by with no specific task assigned. This would suggest that optimal use was not made of all available resources, and the important task of warning the passengers in a rapidly developing emergency situation could not be effected. On 11 July 1997, the THOMASRENNIE was closing with Toronto mainland dock No. 2 at her normal speed of approach. The stern engine went astern where and when ordered but it did not develop full power astern in time to stop the vessel from striking the dock. The bow engine did not develop the full power astern ordered in time to assist in stopping the vessel. Contrary to the company standing orders, the master did not retain the mate on the bridge to assist him in docking the vessel. With no Bridge Resource Management (BRM) environment in place, no warning could be given to the passengers when the emergency situation developed. A warning was not broadcast on the public address system nor sounded on the whistle to indicate to the passengers, crew or persons working at the loading apron that the vessel was about to strike either the dolphin or the dock. A passenger and a crew member were injured as a result of the strikings and were taken to hospital by ambulance. The engine repairs undertaken at the stern engine about one hour and a half before the occurrence were not logged into the engine-room log book. The preventative maintenance program for the main engines and auxiliaries does not appear to be capable of preventing system failures or breakdowns. There is a history of engine control problems on the ferry but detailed records of these problems and associated maintenance were not kept. About two years before the occurrence, the existing program of preventative maintenance of the vessel's engine controls was reduced. It is unlikely that a damaged air pressure control valve could have been the cause of the loss of engine control. However, the control valve was replaced before experts from Transport Canada Marine Safety had an opportunity to thoroughly examine and test the vessel's control systems.Findings On 11 July 1997, the THOMASRENNIE was closing with Toronto mainland dock No. 2 at her normal speed of approach. The stern engine went astern where and when ordered but it did not develop full power astern in time to stop the vessel from striking the dock. The bow engine did not develop the full power astern ordered in time to assist in stopping the vessel. Contrary to the company standing orders, the master did not retain the mate on the bridge to assist him in docking the vessel. With no Bridge Resource Management (BRM) environment in place, no warning could be given to the passengers when the emergency situation developed. A warning was not broadcast on the public address system nor sounded on the whistle to indicate to the passengers, crew or persons working at the loading apron that the vessel was about to strike either the dolphin or the dock. A passenger and a crew member were injured as a result of the strikings and were taken to hospital by ambulance. The engine repairs undertaken at the stern engine about one hour and a half before the occurrence were not logged into the engine-room log book. The preventative maintenance program for the main engines and auxiliaries does not appear to be capable of preventing system failures or breakdowns. There is a history of engine control problems on the ferry but detailed records of these problems and associated maintenance were not kept. About two years before the occurrence, the existing program of preventative maintenance of the vessel's engine controls was reduced. It is unlikely that a damaged air pressure control valve could have been the cause of the loss of engine control. However, the control valve was replaced before experts from Transport Canada Marine Safety had an opportunity to thoroughly examine and test the vessel's control systems. The precise mechanical cause of the striking was not determined but is likely to have been a failure of the engine control system due to a reduction in the level of scheduled preventative maintenance. The absence of a Bridge Resource Management environment prevented the master, who was alone in the wheel-house, from warning those on board and on the dock of the striking. A passenger and a crew member were injured as a result of the vessel striking the dolphin and the dock.Causes and Contributing Factors The precise mechanical cause of the striking was not determined but is likely to have been a failure of the engine control system due to a reduction in the level of scheduled preventative maintenance. The absence of a Bridge Resource Management environment prevented the master, who was alone in the wheel-house, from warning those on board and on the dock of the striking. A passenger and a crew member were injured as a result of the vessel striking the dolphin and the dock. It is reported that the owners of the vessel, the City of Toronto, Metro Parks and Culture, have reviewed their procedures and as a result engaged a contractor to visually inspect the pneumatic control system at least twice a year, usually in the spring and fall. The owners have re-emphasized to their masters the need for passenger safety announcements before docking. These announcements remind passengers to remain seated until the vessel has docked. As a further measure, an automatic taped safety message is planned for the 1999 sailing season.Safety Action It is reported that the owners of the vessel, the City of Toronto, Metro Parks and Culture, have reviewed their procedures and as a result engaged a contractor to visually inspect the pneumatic control system at least twice a year, usually in the spring and fall. The owners have re-emphasized to their masters the need for passenger safety announcements before docking. These announcements remind passengers to remain seated until the vessel has docked. As a further measure, an automatic taped safety message is planned for the 1999 sailing season.